dissemination does not always follow the deposit of cholera discharges
in privies, wells, etc., and also that when infection does take place,
it may occur between remote extremes as to time, and therefore cannot
be attributed to infectious germs. Such objections are frivolous,
because we know nothing of the nature or vitality of cholera-germs,
and they are, moreover, drawn from exceptional cases. The power of
infected fomites to develop {730} the disease has been preserved, in a
journey from Arabia into Africa, for at least twelve days, and for
even a longer period in passing from Germany to Chicago, as already
related. It is true of every infectious and contagious disease that it
may possess one or both of these qualities in various degrees--that at
one time it is only exceptionally communicated, and that at another
time it appears to propagate itself virulently. So the phenomena of
cholera may consist of little more than a watery diarrhoea, which may
be so mild as hardly to disable the patient from working, while at
other times the attack may include all those terrible and fatal
symptoms which have won for the disease the name of malignant. That a
certain quantity, or "dose," of the cholera poison is required to
develop the disease, but one that varies considerably in different
cases, may be inferred from these facts: 1. Out of a certain number of
persons equally exposed to receive the disease, only a portion may be
attacked at all, and these in very unequal degrees. 2. Persons so
slightly affected as to be ignorant of the nature of their sickness,
and believing it to be an ordinary diarrhoea, may nevertheless become
the innocent, because ignorant, disseminators of cholera. The
explanation of such facts may be manifold: they may depend upon the
dose or upon the energy of the morbid poison, on various possible
conditions of its recipient, and so on; but, however explained, their
reality is none the less certain. The receptivity of persons exposed
to the contagion of cholera is very different. It is well known that
some persons appear to be proof against other contagious diseases,
while others seem never to acquire an immunity from them. On this very
important point the conclusions of Fauvel directly bear.[35] They
include the following propositions: The East Indian ports where
cholera exists as an endemic disease are never the seat of an
extensive epidemic among the native population. But strangers to these
localities are liable to the disease, and such are the Mussulman
pilgrims who come to Bombay to take ship for Mecca. A severe epidemic
of cholera confers upon the locality in which it has taken place an
immunity which in India appears to be of several years' duration. Such
an epidemic in any country is a proof that the cholera is not endemic
there.
[Footnote 35: _Mémoire lu à l'Académie des Sciences_, 1883.]
If a contagious disease preserved its virulence undiminished, it might
continue to prevail indefinitely. But we know that all other
contagious epidemics do come to an end sooner or later, and hence we
must conclude that their specific cause progressively loses its
virulent qualities. There is every reason, therefore, to believe that
the same is true of cholera. Its communicability, and therefore its
diffusion, may vary with climatic, seasonal, local, personal, and
other conditions; but of what nature those conditions are, and
especially of the last and most important, the personal, hardly
anything is known. Nor need we too curiously investigate them, so long
as the fact remains that outside of, and independent of them all,
there is but one essential cause of cholera--a morbid poison as
specific in its nature as that of any of the eruptive fevers--a poison
which no determinable conjunction of circumstances has ever
engendered, and which was unknown in Europe and America before it was
carried to them from India. In just such a way did small-pox first
arise in the Western World. It had never appeared in Europe until the
latter part of the {731} sixth century, when for a short time it
prevailed in Marseilles and the neighboring country. Afterward it was
not heard of until it was reintroduced by the Crusaders on their
return from Palestine in the twelfth century, since which period it
has hardly ever ceased. The history of the diffusion of cholera is
closely analogous to this in several particulars, and we may
reasonably expect that what was in the last generation a new disease
will henceforth be liable to prevail again and again as the
intercourse increases between the nations of the West and the
immemorial source of cholera in Hindostan.[36]
[Footnote 36: Additional illustrations of the communicability of
cholera are contained in the _Brit. and For. Med. Chir. Rev._, July,
1872, p. 56.]
In the preceding discussion of the origin and dissemination of cholera
the broad facts of its specific nature and its contagion by means of
excreta have been chiefly insisted upon. Little has been said either
of the nature of the contagium or of the conditions that modify its
activity. These points will be considered hereafter. But it is proper
in this place to state that, in the opinion of most investigators, the
contagious element has the power of multiplying itself, not only
within the body, but wherever it is in contact with decomposing
organic matter, provided that the degree of heat and amount of
moisture present are adapted to promote such a change, which is
certainly analogous to fermentation, if not identical with it. And the
facts already mentioned may be recalled, which show that the contagium
cannot be a light and subtle substance, since, as has been stated, the
immediate attendants upon cholera patients are not as apt as might be
expected, on that hypothesis, to contract the disease, while
washerwomen inhaling, and probably swallowing, the moist fumes from
cholera fomites much more frequently do so; that fomites saturated
with the dried discharges are very infectious; and that water is the
principal vehicle by which cholera-germs are carried into the stomach.
SYMPTOMATOLOGY.--Like other diseases, cholera occurs under very
dissimilar aspects and with various degrees of gravity. Like those
especially which are caused by specific morbid poisons, it may be so
insignificant as to escape recognition, or, on the other hand, it may
give rise to violent and distressing symptoms which come on without
warning and hurry the patient to inevitable death. Whenever epidemic
diseases present such opposite extremes of severity in their symptoms,
it may reasonably be inferred that the differences depend mainly upon
the quantity of the poison that has been received into the system,
precisely as the dose which has been taken of a narcotic or acrid
poison may be estimated by the gravity of its effects. Individual
peculiarities, constitutional or acquired, may modify the
characteristic phenomena, and sometimes a careful inquiry may be
necessary even to detect their existence; but a study of cholera in
all its grades shows that its symptoms are all the effects of one and
the same cause, and that the cholera poison acts primarily upon the
gastro-intestinal mucous membrane. It follows, as a matter of course,
that, being thus applied, it will occasion symptoms differing in
degree and in kind according to the energy of its action, and that
this, again, will depend partly upon the inherent virulence of the
agent and partly upon its quantity. In fact, this feature in the
clinical history of the disease can be explained only by the operation
of a special irritant acting with different degrees of power upon the
gastro-intestinal {732} mucous membrane. In other words, the different
forms under which it is convenient clinically to recognize and
describe cholera are nothing more than different degrees of the
operation of one and the same poison, modified more or less by the
peculiarities of individual patients. In the most typical of the
fully-formed cases of cholera there is a stage of diarrhoea, a stage
of cholera morbus--_i.e._ of vomiting and purging--with more or less
evidence of stagnation of the blood, which is followed either by
reaction and recovery or collapse and death. The phenomena of those
several stages will now be described, after which certain symptoms
will be more particularly considered.
It has more than once been pointed out that, however mild an attack of
cholera may be, the dejections accompanying it are infectious, and may
produce in other persons the gravest types of the disease. Hence the
importance, not only to the patients, but also to others, of
recognizing it in the earliest stage; for while this knowledge may
suggest measures for preventing an extension of the disease, it leads
to the prompt use of remedies at the only period in which their
success can at all be counted upon. The characteristic of this stage,
which has generally been called either choleraic diarrhoea or
cholerine, is a diarrhoea remarkable for its profuseness and the
frequency and serous quality of the stools, which are, however, of a
more or less yellow color. They are preceded by rumbling and gurgling
noises in the abdomen, are voided without colic or tenesmus, and are
followed by a remarkable sense of exhaustion or faintness, which is
sometimes also accompanied with nausea, and, if they are very frequent
and copious, cramps are apt to be felt in the calves of the legs. In
this variety or stage of the attack, as a rule, there is not any
vomiting; there is complete anorexia, but urgent thirst, a white and
clammy tongue, and a peculiar alteration of tone, a huskiness,
faintness, or hoarseness of the voice. The stools vary from six to
twelve a day, and, as above stated, are slightly yellow; they are also
alkaline, and on standing deposit a granular sediment which consists
largely of the débris of intestinal epithelium. Unless the attack is
very severe the temperature is not lowered by much more than 1° F. The
symptoms now described, especially in their milder grades, may last
for a week or even longer, and then, according to circumstances, end
either in cure or in fully-developed cholera; but under appropriate
treatment they usually subside in a day or two, and more or less
rapidly according to the degree of damage done to the digestive mucous
membrane.
Between the above, which is the mildest type of epidemic cholera, and
the fully-developed disease must be placed that grade of the disease
which is more appropriately called cholerine, comprising cases in
which vomiting occurs as well as purging, with increased debility and
a tendency, more or less decided, to collapse. The matters vomited,
after the rejection of undigested food, are at first bilious, but they
gradually become less and less so the longer the attack lasts, and,
together with the stools, assume the appearance of rice-water--_i.e._
they consist of a pale grayish, semi-transparent liquid in which white
flocculi are suspended. Its reaction is alkaline, and it has a faint
albuminous or spermatic smell. Along with these symptoms the other
effects of serous depletion arise--debility with pallor, duskiness,
coldness, profuse perspiration, and a sodden condition of the skin,
while the secretion of urine is diminished, {733} and all the symptoms
that belong to the first stage of cholera are present in an aggravated
degree.
A curious feature of this disease is that sometimes the onset even of
its graver forms is not attended by any evacuations, although the
stomach and intestine may be filled with liquid. It is perhaps chiefly
in such cases that the patient experiences a rapid depression of all
the mental and physical faculties. The senses are irritable, the head
aches and is confused, there is a disinclination to sleep, the limbs
totter under the weight of the body, the pulse is frequent and feeble,
occasionally fainting takes place; the skin is cool and bedewed with
perspiration. In other cases, again, the attack is sudden; the patient
is smitten with an unaccountable feebleness, speedily followed by
profuse vomiting and purging and general spasms, and dies without any
suspension of the symptoms or any tendency to reaction.
But more usually the attack begins with the diarrhoea and vomiting
described above, which then assume, more or less rapidly, a high
degree of violence, expressed by their frequency and excess. The
stools with proportionate rapidity lose all their fecal qualities and
acquire the rice-water appearance before mentioned, and the liquid
rejected by vomiting in all respects resembles them. It is poured
forth less by an ordinary act of vomiting than by gushes, as if it
overflowed from the throat and mouth; and it often escapes from the
stomach and the bowels at the same instant. Such profuse evacuations
necessarily occasion an urgent thirst which cannot be satisfied, for
liquids are thrown up immediately on being swallowed. Sometimes a
distressing hiccough accompanies these symptoms. It is indeed only one
of the many spasms which may affect the muscular system. They
generally begin in the fingers and toes, which become bent and stiff;
they seize upon the muscles of the calves of the legs, and render the
muscular wall of the abdomen as hard as a board. The pain they produce
is extremely severe, and unless the patient is exceedingly prostrated
he endeavors to assuage it by a constant change of position.
At this period the debility is very great, and progressively
increases, and the patient is unable to rise, or even to move at all
except under the stimulus of the painful spasms. The features are
shrunken; the nose is sharp and pallid, and bent to one side; the
dusky, lack-lustre, and sunken eyes, the thin lips, the hollow cheeks,
and the contracted muscles that stand out like cords under the tense
and clammy skin, present a physiognomy that belongs to no other
disease in the same degree. The hands and feet grow cold, and steadily
the coldness creeps upward toward the trunk; the temperature falls to
94° or 95° F.; the feeble and even flickering pulse ranges from 100 to
120. The integuments of the limbs are shrivelled and damp, and look as
if they had been macerated in water; and if a fold of the skin is
pinched up it subsides very slowly indeed. The eyes grow dull and dry,
the tongue has a pasty or sticky feel, and the urine is almost
suppressed. If any of this excretion can be obtained for examination,
it is found to contain both albumen and sugar. As the attack advances
the patient falls into a dull, listless, and motionless state, which
may be mistaken for insensibility or even unconsciousness but is
really due to exhaustion of all the faculties of mind and body. He may
express no interest in anything, and hardly notice the {734} attention
or the distress of his friends, yet he will generally give clear,
although languid, answers to questions, and fall again into an inert
and unobservant state.
As these symptoms continue and the fluids of the body decrease, the
blood accumulates and stagnates in the veins, giving to the hands and
feet, the nose and lips and other features, to the neck, and even to
the entire surface of the body, a bluish, leaden, or violet tint,
precisely like that of cyanotic children. The pulse, that was already
weak and thready, is no longer perceptible; the carotids even and the
impulse of the heart cease to be felt, and the second sound of the
latter becomes inaudible. The skin is everywhere cold; the hands,
feet, and face are sometimes of an icy coldness, and yet the patients
seldom perceive that they are so; indeed, complaint is more apt to be
made of suffering from internal heat. Even the breath as it issues
from the nostrils feels cold. The blood no longer circulates, and the
heart seems still. If a vein is opened a few drops of black and viscid
blood will trickle from the wound, which if it coagulates, yields but
little serum, and in place of a firm clot only a diffluent jelly. The
voice has sunk to a mere whisper or is quite extinct. The features
assume a distorted and frightful expression; the temples and cheeks
are hollowed; the nose is twisted and pointed, and the nostrils are
obstructed with dry and powdery crusts; the eyes are also dry, dull,
and sunken behind the half-closed and purple lids; the conjunctiva is
no longer moistened by its secretion and becomes bloodshot; the
temperature in the mouth may fall to 79° or 80° F.; a viscid
exhalation bedews the icy and marbled skin; and the whole body is so
shrunken from its natural proportions as to lose all the marks by
which its identity has been recognized. From this pulseless,
exhausted, cold, and cyanotic condition there can be but one step to
death. It generally comes on gradually, the patient sinking into the
state of apparent insensibility before mentioned; on the other hand,
he may expire suddenly on attempting to make some unusual effort.
At any period in the progress of cholera, except that of complete
asphyxia, the contest between the system and the disease may be
decided in favor of the former. If this occurs before profuse
evacuations have taken place or blueness of the skin appeared, the
recovery may be gradual and present no special phenomena. The pulse
regains by degrees its natural force; the skin grows warm again, first
upon the trunk and afterward upon the extremities; the breathing
becomes easy, and, the diarrhoea having already ceased, convalescence
is established. But in proportion to the severity of the symptoms, the
intensity and duration of the cold stage, the cramps, and the
evacuations, will there be a tendency to febrile reaction, with more
or less passive congestion of the internal organs, and therefore a
slower return to health. If the attack has been very severe, and
particularly if the algid stage has been prolonged, fever of a low
type is apt to occur, and indeed may terminate fatally. This fever
presents all the characters of the typhoid state, and is marked by
dryness of the tongue, a brown crust upon the teeth and gums, jerking
of the tendons, delirium, and coma. These symptoms are partly
evidences of exhaustion, of inability of the system to resume its
normal action, and perhaps also they denote the retention of the
effete products of nutrition in the blood; but sometimes they appear
to be associated {735} with, and caused by, a local and latent
inflammation of low grade, established usually in the lungs. Again,
the nervous system seems to bear the brunt of the reactionary effort,
and the patient is attacked by convulsions or perishes in an
apoplectic fit. These phenomena appear to be due in most instances, if
not in all, to renal obstruction, and, as it is supposed that their
immediate cause is the retention of urea in the blood, they have
received the title of uræmic. In other cases a wasting diarrhoea, due
probably to the damaged state of the intestinal mucous membrane, is
superadded to the already existing typhoid state. Occasionally the
parotid glands become enlarged and painful, and sometimes a measly or
roseolous eruption appears upon the skin.
It frequently happens that the convalescence from cholera is slow and
irregular. The system seems to be shattered by the trial it has passed
through; the nervous susceptibility is for a long time morbidly
increased, or, what is still more usual, the digestive function is
greatly impaired. The appetite is capricious and the digestion feeble.
The mouth is pasty, the abdomen tympanitic, the bowels are irregular
and alternately confined and relaxed. Finally, patients who leave the
bed too soon or indulge prematurely in their ordinary diet are liable
to a relapse, perhaps fatally, into the original disease. It has
sometimes happened that such a relapse has taken place several days
after an apparent restoration to perfect health.
COMPLICATIONS AND SEQUELÆ.--In a small proportion of cases, as above
stated, cutaneous eruptions have been observed during the attack of
cholera, or rather during its decline, for they coincide with the
reaction or follow it, and may be regarded as indications of
increasing vitality. They belong to the exanthematous class, and
comprise roseola, erythema, urticaria, and rarely vesicular
eruptions.[37] But, instead of them, there may occur destructive
tissue-lesions in the form of abscesses or ulcers. These affections
are more usual on the limbs than on the trunk or face, but some of
them may appear even in the mouth or fauces. Profuse sweats have been
noticed elsewhere, and the important fact that they carry off large
quantities of urea, which they deposit upon the skin. Diphtherial
exudation has also been met with upon tender parts of the skin and in
the fauces, as well as in the stomach and intestine. In some epidemics
of cholera suppuration of the parotid gland is occasionally observed,
while in others it may be entirely absent. Instances have been
reported of double parotitis, and in several of them the termination
of the attack was fatal. Still more rarely suppuration of the
submaxillary or the cervical glands has been met with. Another sequela
of cholera is a tetanic contraction of the flexor muscles of the
limbs. Between the tenth and fifteenth days of convalescence the
patient is attacked with a tearing, rending pain in the hands and
forearms, the legs and feet, followed by tonic contraction of the
flexor muscles of these parts. The sensibility is not impaired. The
attack lasts for one or several days, and seems always to end in
recovery (Guterbock).
[Footnote 37: Compare _London Hosp. Reports_, iii. 457.]
* * * * *
Some of the individual symptoms of cholera call for a more detailed
notice than they have received in the foregoing epitome, in which the
continuity of the narrative could not be interrupted by a description
of variations depending upon the stage and grade of the disease.
{736} The first to be considered is the temperature. The animal
temperature in cholera varies according to the part of the body at
which it is taken more than in any other disease. In cases of average
severity it rarely falls below 95° F. in the axilla. The temperature
under the tongue does not furnish trustworthy indications. In the
stage of asphyxia it seldom exceeds 87.8° F., and even in cases that
recover it may fall to about 78.8° F. (Wunderlich). In the cold stage
it is not uncommon for a difference of temperature to be noted of
nearly ten degrees between the axilla and the rectum. In a female aged
thirty-two the temperature in the axilla was 93° F., and that in the
vagina 102.8° F. (Mackenzie). In other cases a vaginal temperature of
104° F., and even of 108.32° F., has been reached (Guterbock). Such
high temperatures furnish an unfavorable prognosis. As Wunderlich has
pointed out, during the algid stage temperatures taken in the mouth do
not give an accurate idea of the general temperature; the rectal and
vaginal temperatures are more nearly correct. The following are some
results of thermometry in 74 cases of cholera: Lorain found the
minimum rectal temperature in 1 case 93.2° F., in 2 cases 95°, and in
10 cases 96.8°. In 47 cases the normal temperature was preserved; in
27 it rose to 100.4°; in 15 cases to 102.2°; and in 1 to 104° F.
Leubuscher gives the average temperature in the armpit 92.7° F.; under
the tongue, 90.5°; upon the tongue, 81.5°, in the nostrils, 79.2°; and
on the palm of the hand, 84° F. These numbers, however, only represent
averages. It should be noted that the low temperature of the mouth and
nostrils is caused not only by the evaporation from the surface of
those cavities, but also by the relative coldness of the expired air,
due to the partial suspension of the passage of blood through the
lungs, and therefore to the heating of the air contained in them.
According to Leubuscher also, the lowest temperature is found in the
nostrils, and next under the tongue, and at the latter point it may
vary from 79° F. to 90.5° F. In death by asphyxia the vaginal and
rectal temperatures may rise to 104°-108° F. The axillary fluctuates
less than the internal temperature. It is remarkable that during the
algid stage the patients, at least before the temperature has reached
its minimum, are not conscious of their coldness, but, on the
contrary, complain of internal heat, precisely as happens in the
congestive forms of periodical fever. When the febrile reaction
assumes a typhoid type the temperature in many cases is normal or only
slightly elevated, and it is of serious import if the temperature then
sinks again below the normal grade (Wunderlich). On the whole, the
maintenance of a uniform temperature, neither much above or below 90°
F. in the axilla or under the tongue, may be regarded as favorable,
yet recoveries have taken place even when the temperature at these
points has fallen to 79° F. If the temperature of the parts just
mentioned should rise rapidly to 104° F., it may be regarded as a very
unfavorable sign.